Daily waiting time management for modern radiation oncology department in Indian perspective

1. 1
© 2022 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow
Gagan Saini1
,
Sanjukta Padhi2
,
Kanhu Charan
Patro3
, Rashmi
Shukla1
, Sujit
Kumar Shukla4
,
Deepak Arora1
,
Thomas Ranjit
Singh1
,
Chitaranjan
Kundu3
,
P. S.
Bhattacharya3
,
Ventakata
Krishna3
,
Palla Madhur2
1
Department of
Radiation Oncology,
MAX Superspeciality
Hospital Patparganj
and Vaishali,
4
Department of
Radiation Oncology,
Vardhaman Mahavir
Medical College
and Safdarjang
Hospital, New Delhi,
3
Department of
Radiation Oncology,
Mahatma Gandhi
Cancer Hospital and
Research Institute,
Vishakhapatnam,
Andhra Pradesh,
2
Department of
Radiation Oncology,
SCB Medical College,
Cuttack, Odisha, India
For correspondence:
Dr. Rashmi Shukla,
Department of
Radiation Oncology,
MAX Superspeciality
Hospital, Patparganj
and Vaishali,
New Delhi ‑ 110 092,
India.
E‑mail: drrash11
@gmail.com
Daily waiting time management for
modern radiation oncology department in
Indian perspective
ABSTRACT
Introduction: Radiation therapy is one of the most technically sophisticated branch of medical sciences which caters to very ill
patients, some of whom may be terminally ill. Since patients are treated on an outpatient basis which requires daily visit to hospital
for a number of days, it can make them sensitive toward any increase in waiting time for their radiation treatment. This could be a
source of stress for them. However, given the technical sophistication involved and varied clinical profile of patients, some amount
of delay is inevitable.
Aim & Objective: To compile and suggest strategies to manage patient waiting time in Radiation oncology department to achieve
optimum patient’ satisfaction.
Method: The radiation oncologists in different institutes of the country were interviewed telephonically and were asked about the
practices followed in their institutes/ departments in managing the patient waiting time during radiation treatment. The best practices
being followed and the suggestions were compiled.
Conclusion: Now it is being recognized that meticulous management of waiting time could go a long way in driving patient’s
satisfaction. Twoway communications are the best strategy. Apart from this many provisions could be made in waiting area as per
institutional preferences and protocol to engage patient in waiting area of radiation treatment facility
KEY WORDS: Patient’s satisfaction, radiation therapy, technical sophistication, twoway communication
Original Article
INTRODUCTION
Healthcare is one of the most important
components of service sector of the economy.
And the motto of service sector is customer’s
satisfaction. Similarly, the success of healthcare
delivery system depends upon the satisfaction
of the end user, i.e., the patients. Patient’s
satisfaction becomes even more important in
the field of radiation oncology where terminally
ill patients are also treated. As treatment with
radiation is given 5 days a week on outpatient
basis, patients become more conscious about the
time spent waiting for the treatment. Any delay
in the radiotherapy schedule would impact daily
routine of the patients and cause more stress.[1]
This in turn may impact the compliance of the
patient affecting the clinical outcome. Hence,
managing patient’s waiting time meticulously is
very important part of radiation treatment.
The field of radiation oncology is highly specialized
branch of medicine involving radiation oncologists,
medical physicists, radiotherapy technologists, and
oncology nurses. Each of them has a defined role
and responsibility to play in the treatment of cancer
patients. Hence, the coordination among them
is of utmost importance. Every day a number of
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How to cite this article: Saini G, Patro KC, Padhi S, Shukla R, Shukla SK, Arora D, et al. Daily waiting time management for
modern radiation oncology department in Indian perspective. J Can Res Ther 2021;XX:XX-XX.
Access this article online
Website: www.cancerjournal.net
Quick Response Code:
DOI: 10.4103/jcrt.JCRT_1481_20
PMID: ***
Submitted:09-Oct-2020
Revised: 01-Jan-2021
Accepted: 03-Jan-2021
Published: ***
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2. Saini, et al.: Daily waiting time management for modern radiation oncology department
2 Journal of Cancer Research and Therapeutics - Volume XX - Issue XX - Month 2022
patients are treated on RT machine of the radiation oncology
department. All patients are provided with a time slot to avoid/
minimize waiting time of the patient. However given the
intricacies involved from planning to treatment, sometimes
waiting becomes inevitable for the patients.
The factors causing increase in waiting time for radiotherapy
treatment could be clinical, technical, and external.
CLINICAL FACTORS
The radiation treatment is very individualized. The protocols
for treatment are site‑specificrequiring individual set‑ups.
Even for the same site, each patient may have different
clinical status and therefore requirements needing special
considerations. These factors result inpatient spending longer
time in treatment room.
The patient set‑up on the treatment couch is generally very
good for treatment for brain tumors. The errors are always
very less[2]
due to rigid anatomy. However, a higher number
of the patients have poor performance status and therefore
require more manpower to set‑up for treatment. This requires
a relatively longer time.
Head‑and‑neck cancer patient’s setup with thermoplastic
masks and individual head rests than other sites with use of
the markings on the mask. This makes it efficient and less
time consuming because the anatomy in this region is fairly
consistent due to the natural prominent bony landmarks.
However, majority of patients can suffer from Grade 3
mucositis by the end of 4 weeks[3]
and majority of skin reactions
develop at 20–40 Gy.[4]
In these circumstances, the set‑up time
increases, especially if accessories such as mouth bites or bolus
are being used.
For the radiation treatment of breast cancer patients, most
centers do not use thermoplastic mold, and therefore
matching the laser with skin markings may take more time
for setup especially for patients with loose skin or who are
overweight.[5]
Understandably, treating left‑sided breast with
deep inspiratory breath hold (DIBH) takes longer time due
to the need for respiratory synchronization.[6]
Most patients
take 3–4 days for respiratory coaching but still on the day
of treatment they may take longer time to achieve a desired
respiratory pattern due to an understandable anxiety and
apprehension.
Patients receiving radiation therapy for lung cancers
also require a longer time for set‑up. The same is due to
relatively lesser prominent bony landmarks in this region.
The patients need to be set‑up as per indexed markings on
the patient’s body. These patients may have been planned
by using motion management techniques such as gating
of breath hold techniques which take more time.[7,8]
Hence,
generally it requires 30 min for conventionally fractionated
treatment of lung cancer and 45 min for stereotactic body
radiotherapy (SBRT) of lung cancer.
When we treat abdominal cancers with fractionated
radiotherapy, set‑up time can be long due to lesser bony
landmarks. Furthermore, the patients may require specialized
protocols for treatment such as empty stomach or motion
encompassing techniques. The set‑up is generally done
using markings indexed with couch positions. Image‑guided
radiotherapy therefore can be particularly useful there.[9]
SBRT spine patients can take longer time for setup because of
severe pain, cord compression, vertebral compression fracture,
and more in cervicothoracic region where movement is more.[10]
Best way to avoid this to give analgesics, anti‑inflammatory
before treatment. Patients with low‑performance score requires
additional manpower and support for getting to the couch. It
generally takes 40–45 min for such patients.
Liver SBRT patients require a longer time for set‑up and
treatment. This is due to the use of motion encompassing
techniques such as DIBH or four‑dimensional computed
tomography (CT).[11]
Difficulties arise while treating the segment
1–4 near the stomach. Even with a period of 4 h fasting, a
slightly distended stomach can come inside the planning target
volume. This can add to the waiting period for a patient due to
multiple time verification which is quite challenging. To solve
this issue, we treat these patients after an overnight fasting
as a first patient on the machine early morning.
Patients receiving radiation therapy to any pelvic site has
its own issues. While every patient needs to follow bladder
protocols for reproducible full bladders,[12‑14]
however, filling of
the bladder also depends on general hydration in a particular
day. Patients in later phase of their treatment may find it
difficult to hold their urine. The patients with a heavy body
weight can make alignment difficult during set‑up due to
relatively lesser prominent bony landmarks. The same may
be countered using more accessories with thermoplastic
mold.[15]
Finally, due to the higher chances of rotational errors,
patients receiving pelvic radiotherapy need to be frequently
repositioned. Its better to keep a slot of 30 min for such
patients.
Treating prostate cancer with hypofractionation or SBRT
with full bladder, empty rectum with bladder and/or rectal
protocol to minimize the toxicity is very challenging. The
patient have to be repositioned again because of inadequacy
of bladder rectal protocol and it prolongs the waiting time of
other patients.[16]
Extremity sarcoma patients may also require a long time
because they may have special/uncertain setups and may
have edema and skin reactions during the course of treatment.
Furthermore, alignment can be difficult due to a long target
area.[17]
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3. Saini, et al.: Daily waiting time management for modern radiation oncology department
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Journal of Cancer Research and Therapeutics - Volume XX - Issue XX - Month 2022
Therefore, it can concluded that the waiting time depends on
the site of the tumor and the complexity of the treatment plan.
It is better to keep an afternoon slot for pelvic malignancies
since the incident issues pertaining to these may be better
handled in the latter part of the day. This is because even
if there are any delays due to bladder protocol, one patient
may be adjusted during that time. We have found that breast
patients may be best suited for the evenings as these cases
do not get delayed and may not disrupt the roster of the
technologists. As discussed before, SBRT takes longer time, so
it is preferred to keep SBRT plan as separate slots.
It is advisable to schedule a gap of half an hour in every 3 h
to reduce the cumulative waiting time to ease the build up of
waiting time during the day.
The patients on rectal and bladder protocol must be provided
with proper counseling.
Average expected treatment time in modern radiation
department using daily imaging is described in Table 1.
TECHNICAL FACTORS
Since radiation treatment is given with sophisticated machines
such as linear accelerator (LINAC) there is always a possibility
of technical glitches in the form of breakdown. Parsons et al.[18]
in their study found that the LINAC breakdown/downtime is
the most common cause of treatment delay. It mostly occurs
during the morning warm up and QA and may happen anytime
of the day with aging of machine. These delays could be
anywhere between 20 min and 150 min whether it could be
resolved locally or by a field engineer.
A study by Wroe et al.[19]
compared the LINAC breakdown in
low‑and middle‑income countries (LMICs) than high‑income
countries. They analyzed from centers in Oxford (UK), Abuja,
Benin,Enugu,Lagos,Sokoto (Nigeria),andGaborone (Botswana).
They deconstruct the linac into 12 different subsystems and
foundthatthevacuumsubsystemonlyfailedintheLMICcenters
and the rate of failure was more than twice as large in six of the
12 subsystems compared with the high‑income country. They
also found that inspite of total of 3.4% of fault, LINAC fault
took >1 h to repair but include 74.6% of the total downtime.
Most of the centers in India are equipped with only one or two
machines and it may not possible to shift patients from one
machine to another because each of those may be full with
their own patients. Therefore, these delays cannot always be
compensated even where two machines may be available and
leads to extension of treatment days sometime.
On the day of planning, there could be technical and functional
issues with CT simulator which may cause delay in planning.
Unavailability of certain accessories not available in duplicates
could further delay the mold room procedure making the
patient wait longer for radiation treatment. Therefore, we
have multiple sets of accessories to minimize waiting time of
patients scheduled for simulation.
Complex planning of Reirradiation, stereotactic
radiotherapy (SRS), SBRT can take longer than usual time.
Radiation Oncologists and Physicists may need more time for
contouring and planning. Quality assurance for SRS and SBRT
techniques also takes longer time. Additional time required,
one to two days, for these activities compare to conventional
treatment is accounted and explained to patient so that his
waiting time on the day of treatment is minimal.
EXTERNAL FACTOR
There could be some external factors prolonging waiting time
for the patient. This could be because of patient reporting
late after their allotted time. The reasons for this could be
numerous such as traffic jam, transport, and logistic issues. In
a private set up there could be an issue with payment which
could be from patient’s end or from insurer’s end. All these
factors might result in increase in waiting time for the patients
and more dissatisfaction.
Ways to manage the patient waiting room
Given the multitude of the factors involved in radiation
treatment some amount of delay and prolonging of waiting
time of some patients is inevitable and good briefing prior
to start of treatment on this aspect prepares patient well
receptive to changing situations. However meticulous
management of waiting time of patients could result in higher
satisfaction among the patients.
A study by Vieira et al.[20]
studied pretreatment workflow of
a large radiotherapy department of a Dutch hospital about
scheduling of the first irradiation session. It was set right after
consultation (pull strategy) or be set after the pretreatment
workflow has been completed (push strategy). There was 12%
lower average waiting times and 48% fewer first appointment
rebooks using hybrid (40% pull/60% push) strategy. There was
21% reduction in waiting times by spreading consultation slots
evenly throughout the week.
Table 1: Average expected treatment time in modern
radiation department using daily imaging
Site Duration (min)
Brain 10-15
Head and neck 10-15
Breast 10-15
Breast (left) DIBH 20-30
Lung (conventional) 20
SBRT lung 40-45
Pelvis 20-30
SBRT spine with Exac Trac 25-30
SBRT liver (DIBH) 30-45
SRS brain 45-60
DIBH = Deep inspiratory breathe hold, SBRT = Stereotactic body radiotherapy,
SRS = Stereotactic radiosurgery
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4. Saini, et al.: Daily waiting time management for modern radiation oncology department
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We can have different sets of strategies for different factors
causing delay. Some of the suggestions are:
1. First and foremost is establishing a healthy and assuring
communication with the patient. Gesell and Gregory[21]
in their survey outlined 28 priority actions to improve
patients’ satisfaction. Out of these 28 items, “staff
sensitivity to personal difficulties and inconvenience” is
ranked the most important and number one priority
2. Not to review all patients same day. This could be achieved
by dividing patients for review on different days. Only
patients with complaints could be reviewed on any day
3. Having limited discussion with the patients and
attendants: All the patients should be explained about
the radiation treatment and its predictable side effects
before starting the radiation treatment. Once treatment
is started discussion should be minimized during review
days to avoid delay in treatment. Thus avoiding other
patients from waiting
4. All the patients should be advised to collect reports before
reporting for review
5. Patient on concurrent chemoradiation, should report for
chemotherapy well in advance so that the chemotherapy
gets over before the RT treatment slot of the patients. The
co‑ordination between radiation oncology team, medical
oncology team, and the patient is very important
6. It would be prudent to plan the patient before patient come
to the department. Once treatment plan is finalized with
everyone on board, then only patient should be called for
the treatment
7. In case of Linac breakdown patient should be informed
on phone so that they don’t have to come to the hospital
and return back without treatment session. For patients
who have already arrived for treatment, explaining and
assuring them would be the right strategy. To remain
engage with patients through phones would be more
assuring during the period of breakdown. One staff could
be deputed for this purpose
8. To save the patient from waiting and to have substitute
for the first one in case of breakdown Twin LINAC is the
best idea. The beam data for both the machine is generated
and adjusted in a comparable way. The same beam data
model is used for both machines reducing the calculation
time and same plan can be used on second LINAC. If there
are a breakdown and vice versa. There will be only one set
of quality checklist including tolerance value reducing the
time and efforts for commissioning and quality assurance.
Thus, giving the satisfying results and reducing patient
waiting time in case of breakdown[22]
9. An experienced and well‑trained team can handle complex
treatments efficiently with great patient satisfaction.
Institutes should invest in training of involved staff at all
levels for high performance.
Apart from the above strategies, engaging patients and
attendants during waiting time can also play a big role in
driving patient’s satisfaction.
The patient’s comfort and satisfaction should be kept in
mind while planning and designing the waiting room. The
seating arrangements and lighting along with sound system
should be done so as to predict patient’s satisfaction and
experience of pain.[23,24]
Longer the waiting lower is the patient
satisfaction.
However, by keeping them occupied during the wait, their
satisfaction could markedly be increased, even if the waiting
time remains unaltered.[25]
For this certain provisions can be
made in the waiting area:
1. A facilitator or co‑ordinator could be appointed for
communication with the patients in waiting area. Few
words from hospital staffs could be very assuring to the
patients and will lessen their anxiety and apprehension
2. Provision for engaging patients in the waiting area in the
form of some light indoor activity would be very refreshing
and entertaining for the patients and their attendants. At
same time this would give them opportunity to interact
among themselves and share their experiences
3. TV screens with news, spiritual some light music could be
truly engaging. Recorded messages from cancer survivor
wouldmakethepatientsandtheirattendantsmorepositive
and receptive towards their illness and treatment
4. A small reading corner could be created with tables and
chair with some reading stuff like newspapers, magazines,
books etc., Books with pictorial messages could be very
engaging and impressive
5. AV videos and information booklets with information
about side effects of radiation treatment on different sites
and how to overcome it should be displayed. It makes the
work of counsellor easier
6. Some information regarding rehabilitation in cancer
survivors could be very interesting. It is the loss of function
that decreases the morale of the cancer patients. Any video
demonstration showing them near normal life post cancer
treatment could have the most positive psychological
impact on the patients and their relatives.
CONCLUSION
These are some of the measures that will help enhance
patient satisfaction and avoid stress arising out of prolonging
of treatment time. Different institutions might have their
own protocol for managing such issues, but two‑way
communication is the most effective tool when it comes to
assuring anxious patients. However, there are not many studies
conducted on the effect increased of waiting time on patient’s
satisfaction and literatures are scarce. A scientific study of
different aspects of delay or prolonging of treatment waiting
time for radiation treatment will go a long way in dealing with
this important issue concerning radiation oncology.
Financial support and sponsorship
Nil.
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5. Saini, et al.: Daily waiting time management for modern radiation oncology department
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Conflicts of interest
There are no conflicts of interest.
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